Dedicated teams to optimize quality and safety of surgery: A systematic review

Abstract Background A dedicated operating team is defined as a surgical team consisting of the same group of people working together over time, optimally attuned in both technical and/or communicative aspects. This can be achieved through technical and/or communicative training in a team setting. A dedicated surgical team may contribute to the optimization of healthcare quality and patient safety within the perioperative period. Method A systematic review was conducted to evaluate the effects of a dedicated surgical team on clinical and performance outcomes. MEDLINE and Embase were searched on 23 June 2022. Both randomized controlled trials (RCTs) and non-randomized studies (NRSs) were included. Primary outcomes were mortality, complications and readmissions. Secondary outcomes were costs and performance measures. Results Fourteen studies were included (RCTs n = 1; NRSs n = 13). Implementation of dedicated operating teams was associated with improvements in mortality, turnover time, teamwork, communication and costs. No significant differences were observed in readmission rates and length of hospital stay. Results regarding duration, glitch counts and complications of surgery were inconclusive. Limitations include study conduct and heterogeneity between studies. Conclusions The institution of surgical teams who followed communicative and/or technical training appeared to have beneficial effects on several clinical outcome measures. Dedicated teams provide a feasible way of improving healthcare quality and patient safety. A dose–response effect of team training was reported, but also a relapse rate, suggesting that repetitive training is of major concern to high-quality patient care. Further studies are needed to confirm these findings, due to limited level of evidence in current literature. Prospero registration number CRD42020145288


Introduction
An essential part of incidents in healthcare takes place in the perioperative process. The complexity of technical, logistical and communicative interactions creates a high-risk environment for patients [1]. The multitude of players and handovers in this process make it vulnerable for mistakes, information loss and communication errors [2,3]. Moreover, the operative process is constantly changing. Perpetual improvement and adjustment are mandatory to ensure patient safety [1].
Increasing complexity of surgical procedures and eligible patient populations has led to medical specialists super specializing within their field of expertise. This extensive specialization is not always matched by other members of the operating room (OR) team, i.e. scrub and circulating nurses and anesthesiologists. In many cases, team composition changes frequently. When there is a progressive mismatch between super specialists and generalists within one team, it is at risk of communication problems, mismatch of perioperative expectations and non-alignment of the appreciation of the perioperative risk. It seems straightforward that a dedicated surgical team, trained in technical and/or nontechnical skills concerning an intervention, could improve the efficiency, quality and safety of healthcare. However, knowledge regarding the impact of a dedicated surgical team on surgical outcomes is still lacking.
A clear definition of a dedicated surgical team is still lacking. Relevant literature focuses on either technical training or pure nontechnical skill training. In our opinion, a true dedicated team is trained in both technical and nontechnical skills, as a team. In this review, a dedicated surgical team is defined as a surgical team consisting of the same group of people working together over time, optimally attuned in technical and/or communicative aspects, ideally both. This can be achieved through communicative and technical training in a team setting. Team composition and team training are essential components of a dedicated team; however, with varying team compositions being frequent, especially in larger medical centers, team training is considered the most important aspect of a dedicated team.
Previous literature focused on nontechnical skills training for surgical teams found communication and teamwork to improve following training, with effects remaining visible for a varying period [4][5][6][7].
Team training was also found to enable the cultivation of a shared mental model; that is where surgical staff have a mutual awareness regarding the intricacies of the operation and clear allocated tasks and roles [8]. Team familiarity, which can establish a shared mental model, has been found to have a positive impact on performance including surgical time reduction [8].
The most extensively studied training is crew resource management (CRM) for OR teams [9,10]. CRM is adapted from aviation aiming to reduce human errors in high-stakes environments [9,10]. Nonetheless, CRM training is not uniform across studies; there are essential differences in what is incorporated in CRM and the recommended frequency of provided trainings [10,11]. In all cases, the first step should involve defining the problem that needs to be addressed during training. An exact purpose of the intervention should be established; providing CRM is not a goal on itself. The selection of clinically relevant measures to monitor outcomes of the intervention poses a challenge [10]. In most cases, complications or mortality are confounded by several factors and hence potentially inaccurate measures in a complex environment.
The aim of this review was to determine whether a dedicated surgical team trained in communicative and/or technical skills contributes to the optimization of healthcare quality and patient safety within the perioperative period. Clinical outcomes, performance measures and costs were considered to establish whether dedicated surgical teams result in superior outcomes compared to non-dedicated surgical teams.

Patient and public involvement
No patients were involved in this study.

Definitions
In this study, a dedicated surgical team was defined as a surgical team, optimally attuned in technical and/or communicative aspects. Teambuilding could be performed through communicative and technical training in a team setting. A dedicated surgical team includes surgeon, scrub and circulating nurses, anesthesiologist, nurse anesthetist and may include additional members (i.e. perfusionists).
Glitch counts refer to disturbances during surgery and are expressed as number of glitches per surgery per hour. Turnover time refers to time from when a patient leaves the surgical room until another patient enters the same surgical room.

Search strategy and selection criteria
The MEDLINE (via Ovid) and Embase (via Embase.com) databases were searched on 23 June 2022. Relevant search terms for operations and dedicated teams were used, in combination with search terms regarding clinical outcomes or safety (supplementary file 1). PICOS (Population, Intervention, Control and Outcomes) criteria are shown in supplementary file 3. Clinical outcomes included mortality, complications and readmissions. Secondary outcomes were costs and performance measures, including length of hospital stay, glitch count, operating time, turnover time, teamwork and communication.
Studies were selected, based on the following selection criteria: conducted after the year 2000, randomized controlled trials (RCTs) or non-randomized comparative studies (NRSs; including before-and-after studies) comparing outcomes following the use of a dedicated surgical team versus a non-dedicated surgical team, a sample size of at least 20 surgeries, conducted in the Western world and reporting at least one clinical outcome parameter (mortality, postoperative complications and readmission rate). These selection criteria were chosen to ensure that studies were conducted in comparable settings to those seen in Dutch surgical clinics, allowing for translation of results into practice.

Selection procedure
Papers retrieved during the database searches were selected by a two-step screening process. A dual independent review of the search results, based on title and abstract, was conducted by two reviewers (M.L. and R.L.W.). During the second step, full-text evaluation was performed by the same two reviewers. Discrepancies in the study selection were resolved by group discussion (M.L., R.L.W. and F.W.).

Risk of bias
For determining the risk of bias in the RCTs, an adjusted version of the Cochrane Risk of Bias Tool was used and for NRSs, the Newcastle-Ottawa tool (see Tables 3-4) was used.

Selected papers
The search yielded 890 records (after duplicate removal). After a review based on title and abstract, 116 studies were selected for full paper evaluation. After this evaluation, 106 more studies were excluded. Reasons for exclusion included not meeting the research question, lack of clinical outcomes, non-comparative studies and not being an original study (see the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart, supplementary file 2). Additional sources, obtained by reference checking from selected studies, yielded four extra eligible studies.
Fourteen studies were included in this systematic review (RCTs n = 1; NRSs n = 13). The most important characteristics and results are included in the evidence tables (Tables 1  and 2). The intervention entails team training to form a dedicated team. The approach, duration and frequency of team training vary across studies. Setting, intervention type and outcomes are largely heterogeneous, making it difficult to pool or summarize studies. Results were therefore descriptive; conclusions were drawn where possible.
Assessment of the risk of bias of the individual studies is shown in Tables 3 and 4. Overall, the risk of bias was high.  (i) Before-andafter study (ii) Total joint arthroplasty

Clinical outcomes Mortality
Mortality was assessed in two NRSs and one cluster RCT [12][13][14]. Team training was provided in all three studies (see Table 3 for details). Neily et al. found a reduction in mortality for noncardiac surgery in both intervention (almost 50%) and control groups [13]. However, the reduction was significantly larger in the intervention group (propensity matching: adjusted RR: 1.49; 95% CI 1.10-2.07). A dose-response relationship was observed quarterly during the training program, with a reduction of 0.5 deaths per 1000 operations (95% CI 0.2-1.0). Forse et al. found a significant reduction in mortality from 2.7% to 1% (P < 0.05) 9 months after the intervention in their retrospective cohort [12]. One year later, however, this had increased to 1.5%. Duclos et al. also observed a significant decrease in mortality in both intervention and control groups in their cluster RCT [14]. Nonetheless, there was no significant difference between the intervention and control groups, attributed to flawed methodology. Likely, there was bias due to inadequate blinding of care providers and outcome assessors (ROR 0.81, 95% CI 0.38-1.72).

Complications
Eight studies evaluated a wide range of reported complications [12,[14][15][16][17][18][19][20]. In two smaller studies without control groups, few complications were recorded, and no difference was found before and after implementing the intervention. The subject of the studies was a dedicated robotic team who underwent CRM training plus coaching [15,19].
In three NRSs, fewer complications were seen in the intervention group, but this difference did not reach statistical significance [16,18,20]. Comparing the primary outcome between these studies was difficult, as the setting and type of patients in these studies differed. In a large retrospective cohort study, a significant decrease in morbidity was observed 9 months after the implementation of the intervention (Team-STEPPS program). Complications decreased from 20% to 11% (P < 0.05). After 1 year, a relapse rate was observed with an increase in complications from 11% to 13% (P < 0.05) [12].
In a cluster RCT, a significant decrease in complications was seen in both groups (from 8.8% to 5.5% in the intervention group and from 7.9% to 5.4% in the control group) [14]. Nevertheless, there was no difference between the intervention and control groups (ROR 0.90, 95% CI 0.67-1.21). No differences were seen in major complications or postoperative complications. In contrast, in another controlled before-andafter study a slight, yet significant, increase in complications in the intervention group (21.5% to 26.8%), attributed to an increased glitch count, and a slight decrease in the control group (27.1% to 25.7%) were noted [17].

Readmissions
Four studies looked at readmission rates [15][16][17][18]. None of these found a significant difference in readmission rates between the intervention (treated by dedicated team) and control groups over time.

Performance outcomes Efficiency
Length of hospital stay Seven studies reported on length of hospital stay [15-19, 21, 22]. For this outcome measurement, the treatment by a dedicated team made no difference.
Glitch count No study was able to show a reduction in glitch count for dedicated teams [16,17,23]. Nonetheless, in dedicated teams, the amount of technical operative mistakes and nonoperative procedural mistakes was lower than that in non-dedicated teams [23]. These outcomes are however not comparable to glitch count.
Surgery duration and turnover time There are conflicting results regarding the effect of a dedicated team on surgery duration. Four studies found reductions in surgery time when using a dedicated team, ranging from 7% to 30% reduction in surgery time and a 5% reduction in anesthesiology time [15,19,20,24].
In contrast, two studies saw an increase in surgery time [17,22]. Morgan et al. saw a small non-significant increase, and Lim et al. found an increase in surgery duration in the acute setting; however, the time from admission until decision to operate was significantly shorter [17,22].

Teamwork and communication
Oxford NOTECHS II Improvements in Oxford NOTECHS II (a rating system for nontechnical skills of a surgical team) over time were observed in all studies, with most improvement seen in the dedicated teams [16][17][18][19]23]. The improvement of nontechnical skills was only significant for nurses or for anesthesiologists, but never for surgeons [16][17][18].
Teamwork and team communication Team climate and teamwork improved in a dedicated team, as assessed by the Safety Attitudes Questionnaire (SAQ) and a program-specific questionnaire [12,19]. A non-significant improvement of team communication after 9 months was reported by the dedicated surgical team, assessed by a program-specific questionnaire [12].

Costs
Three studies evaluated cost outcomes [20,24,25]. Two studies found statistically significant reductions in cost [20,24]. Flynn et al. reported an average cost reduction of $8900 and $6000 for more complex cases [20]. Rebuck et al. noted that anesthesiology-related costs remained the same, but total costs decreased with 22% [24]. One study from the USA reported a 20% increase in OR revenue, attributed to increased efficiency [25].

Statement of principal findings
This systematic literature review is the first to evaluate the effects of a dedicated surgical team on clinical outcomes and performance measures. Effective implementation of a dedicated team is often assumed to be advantageous, but in clinical practice sometimes difficult to realize. This review provides an analysis of benefits for the development and implementation of dedicated teams. Implementation of dedicated surgical teams was found to be associated with improvements in several outcomes, including mortality, turnover time, nontechnical skills, teamwork, team communication and costs. No significant differences were observed in readmission rates and length of hospital stay. The effect of a dedicated surgical team on operation time, disturbances and complications remains unclear, due to inconsistent findings.

Interpretation within the context of the wider literature
The improvements in outcomes following the implementation of a dedicated surgical team are in agreement with literature regarding the positive effects of surgical team training [1,8].
An overall decrease in mortality was observed, when studying surgical teams over time. Whether the formation of a formal dedicated team adds to this remains controversial [12][13][14]. Follow-up time, intervention type and frequency at which trainings were given, was inconsistent across studies. The effect of a dedicated surgical team on complications remains unclear as results were inconsistent across studies. A wide range of complications was investigated, making it difficult to compare and draw conclusions [12,[14][15][16][17][18][19][20].
Results regarding glitch counts were contradictive. While in most studies, fewer technical operative mistakes and nonoperative procedural mistakes were reported in the dedicated team, in one RCT more glitches were observed; the reason behind the worsened glitch counts remains unclear [16,17,23]. The effect of dedicated surgical teams on surgery duration remains unclear, due to inconsistent results [15,17,19,20,22,24]. One study attributed increased surgery duration to more teaching taking place during surgeries [22]. However, most studies found the effect of dedicated teams on surgery duration to be beneficial [15,19,20,24]. Turnover time and costs were found to be significantly reduced by implementing a dedicated surgical team [12,20,21,24,25]. Cost reductions were attributed to increased efficiency and reduced turnover time, and hence, reductions in wages, surgical equipment and use of surgical theaters [20,24]. In line with this finding, teamwork improved [12,21,24]. In four out of five studies, significant differences existed in nontechnical skills between intervention and control groups [16][17][18][19]23]. In accordance, the implementation of a dedicated surgical team was associated with a significant improvement in teamwork [12,19]. Although team communication was also found to improve after the intervention, this did not reach statistical significance [12].

Strengths and limitations
The strengths of this review include the comprehensive search strategy developed by an information specialist and discussion between reviewers in case of doubt. Moreover, a wide array of outcomes and settings was considered to evaluate dedicated surgical teams.
The level of evidence regarding clinical, efficiency, teamwork, communication and cost outcomes is limited because of study conduct. Most studies were observational studies with little to partial correction for confounders, leading to inconsistent results. This review is limited by the quality and the data of the included studies. Most studies had some significant drawbacks in study design and a large variety of interventions, settings and recorded data, making it hard to compare and draw conclusions.
A fundamental limitation is the lack of a clear definition of what a dedicated team entails and how such a team should be formed. As a result, studies have interpreted a dedicated team in various manners. The formation of a dedicated team varied across studies; from teams receiving little trainings to teams receiving frequent trainings over the span of months. Furthermore, not all teams received technical and communicative team training; in an ideal scenario this would have been the case. Whether there can be a universal definition of a dedicated team is unclear; surely what 'dedicated' entails varies per specialism and setting. We propose that a surgical team is everybody in the OR with a role in the care for the patient. The team becomes dedicated when these individuals train together in technical and nontechnical skills. Attention should be paid to the frequency and continuity of training sessions as dose-response and relapse rates were seen. Furthermore, a standardized set of core outcomes could help overcome problems in measuring the effects of a dedicated team.
Moreover, there is no ideal outcome to measure the effect of the intervention. When considering clinical outcomes, mortality and complications are confounded by many factors. Performance outcomes are also confounded by several factors, making it difficult to draw conclusions. Glitch count is used as a proxy for surgical efficiency, but what exactly entails a 'glitch' remains unclear and may differ between studies. The cost-benefits of implementing a dedicated surgical team are interlinked with surgical efficiency; one could say that a more efficient surgery is also cheaper.

Implications for policy, practice and research
The main implication of this review is that a dedicated surgical team, through team training, may contribute to the optimization of healthcare quality and patient safety within the perioperative period. Through team training, technical and nontechnical skills may improve, increasing the level of teamwork and effectiveness of communication. This leads to better efficiency of the operative and perioperative processes, reducing costs. Moreover, this reduces mistakes and mortality. The sustainability of implementing a dedicated surgical team needs to be further investigated, as only a few studies have evaluated this. A dose-response effect of team training and a relapse rate were reported [12,13]. This is in-line with findings in other studies regarding nontechnical skills training for surgical teams [4].
The implications of these results have been assimilated into a recommendation in the Dutch perioperative guideline [26].
The generalizability of these results also needs to be further investigated. This review mainly looked at complex procedures. One could hypothesize that dedicated surgical teams yield most benefits during highly specialized and routine surgeries. In highly complex interventions, the mismatch between highly specialized surgeons and nonspecialized team members is the greatest, suggesting that dedicated teams could provide most benefits in this setting.

Conclusion
This systematic review summarizes the potential benefits of dedicated surgical teams in the perioperative setting. It seems to be beneficial to offer team training to improve technical and/or nontechnical skills of surgical teams. Dedicated teams could help optimize healthcare and increase comprehension of each other's actions [27,28].
However, further studies are needed to draw conclusions, as the level of evidence was often low. Standardized team training, settings and methods of recording outcomes, for both technical and nontechnical skills, could help in comparing studies and group results.

Supplementary material
Supplementary material is available at International Journal for Quality in Health Care online.

Funding
This work was supported by the Dutch Association of Medical Specialists (Stichting Kwaliteitsgelden Medisch Specialist (SKMS)) [grant number 46519978].

Data availability
As this is a systematic review, all data relevant to the study are included in the article, see methods and evidence tables. If further information is needed, this can be requested from f.willeboordse@kennisinstituut.nl.